ACCESS Model: Executive Summary and Model Architecture Analysis

ValuesEdge Strategic Intelligence | Based on CMS Source Documents through October 2026

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1. Executive Summary and Strategic Context

What Is This Model and What Problem Does It Solve?

The Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model is a 10-year voluntary national Innovation Center model that began July 5, 2026 and runs through June 30, 2036. It operates under authority of Section 1115A of the Social Security Act and currently has 160+ participants. The model tests a novel Outcome-Aligned Payment (OAP) methodology designed to create a viable Medicare payment pathway for technology-enabled chronic care organizations — a category that has historically been locked out of Original Medicare due to structural incompatibilities with fee-for-service billing.

The problem ACCESS addresses is concrete and well-documented: there are more than 10,000 technology-enabled care organizations — digital health and digital therapeutics companies — with over $10 billion invested in 2024, yet the vast majority serve commercially insured populations because Medicare's FFS infrastructure cannot accommodate their care delivery model. FFS pays for discrete, defined activities; technology-enabled chronic care is continuous, remote, and often asynchronous. Adapting FFS codes to cover these modalities risks cost inflation because FFS rewards volume, while technology-enabled care has low marginal cost per additional patient interaction. Value-based arrangements like ACOs and Medicare Advantage contracts present a different barrier: their complexity, local market concentration (creating "winner-take-all" vendor dynamics), difficulty attributing condition-specific savings across overlapping interventions, and high implementation costs have made digital health contracting cumbersome even where willingness exists.

ACCESS addresses both problems simultaneously. By introducing a fixed, per-patient, annual payment tied to measurable clinical outcomes — not to the volume or type of services rendered — the model creates a standardized payment lane that technology-enabled organizations can enter without custom contracting and that Medicare can administer through existing claims infrastructure using new G-codes. The model focuses on four of the most prevalent chronic condition clusters in Medicare: early cardio-kidney-metabolic (eCKM), cardio-kidney-metabolic (CKM), musculoskeletal (MSK), and behavioral health (BH) — conditions described in the source materials as affecting three-quarters of Medicare beneficiaries. Starting April 1, 2027, additional tracks will cover heart failure, COPD, substance use disorder, and tobacco cessation without requiring reapplication from current participants.

Strategic Significance for the VBC Market

ACCESS represents a structural intervention in the Medicare payment architecture of a scope rarely seen outside of the Physician Fee Schedule rulemaking cycle. Several features make it strategically distinctive.

First, the model creates a new provider category within Medicare: technology-enabled care organizations that are neither traditional fee-for-service billers nor risk-bearing entities, but outcome-accountable chronic care managers operating as a complement to both. Any Medicare Part B-enrolled organizational entity (excluding DMEPOS and laboratory suppliers) with a single TIN eligible to bill under the Physician Fee Schedule can participate. This explicitly includes virtual-first and digitally native organizations that have previously had no viable Medicare billing pathway.

Second, ACCESS is explicitly designed to complement ACO and shared savings arrangements rather than compete with them. CMS is making system changes so that for 2026 and 2027, ACCESS OAPs will have no impact on ACO benchmark and performance year calculations for the Medicare Shared Savings Program and ACO REACH. Beginning 2028, expenditures will be incorporated into ACO calculations. This transitional accommodation signals that CMS is actively managing the integration of ACCESS into the broader VBC ecosystem rather than forcing an immediate reckoning. ACOs that refer aligned beneficiaries to ACCESS participants can continue doing so while the payment implications are phased in.

Third, the model's billing structure — monthly claims via standard G-codes processed through Medicare Administrative Contractors (MACs), with quarterly payments from the Innovation Payment Contractor (IPC) — is deliberately designed to support multi-payer alignment. CMS is making reference payer implementation resources available to support adoption of aligned payment approaches by Medicare Advantage, Medicaid, and commercial plans. Major health plans have already pledged to offer ACCESS-aligned payment options. This transforms the model from a Medicare experiment into a potential standard-setting event for the broader chronic care technology market.

Fourth, CMS will maintain a public directory of all ACCESS participants showing their conditions treated and risk-adjusted outcomes — a transparency mechanism that creates quality-based competition among digital health organizations for referrals from PCPs and ACOs. For organizations with strong clinical performance, this is a customer acquisition asset. For those with weak outcomes, it is an existential accountability mechanism.

Political Context and Administrative Alignment

ACCESS launches under the second Trump administration, with CMS Administrator Dr. Mehmet Oz and CMMI Director Abe Sutton at the helm. The RFA explicitly frames the model's strategic alignment around the CMS Innovation Center's Strategy to Make America Healthy Again, emphasizing disease prevention, patient empowerment through health technology, and competition-driven innovation — all consistent with the current administration's public messaging around reducing chronic disease burden and expanding consumer choice.

The model's emphasis on outcomes over activities, its reliance on market-developed technology solutions rather than government-prescribed interventions, and its explicit goal of protecting federal taxpayers by conditioning full payment on clinical outcomes all reflect ideological priorities that are bipartisan in their framing but particularly resonant under the current CMS leadership's stated preference for accountable, market-oriented innovation. The participation of leading medical societies in expressing support and major health plans pledging ACCESS-aligned payment options suggests the model has achieved broad stakeholder alignment unusual for a CMMI initiative.

The DOGE-era context — with significant pressure on CMS to reduce expenditure and demonstrate program integrity — makes ACCESS's built-in accountability architecture (the Clinical Outcome Adjustment, the Substitute Spend Adjustment, the randomized evaluation design, and the FFS exclusion preventing duplicate billing) politically important. The model is structured to demonstrate fiscal discipline to oversight bodies while creating a new market access channel for the digital health sector.

Market Transformation Implications

For hospital executives and health system leaders, ACCESS creates an external competitive pressure: technology-enabled organizations can now access Medicare patients directly, without hospital system infrastructure, and will appear in a public directory alongside risk-adjusted outcomes. Systems that have invested in virtual chronic care programs can and should consider joining ACCESS as participants for beneficiaries outside their ACO-aligned population.

For ACO leaders, ACCESS is simultaneously a care delivery tool and a financial planning challenge. The 2028 incorporation of ACCESS OAPs into ACO benchmark calculations requires modeling now. ACOs should assess which of their attributed beneficiaries are candidates for ACCESS referral and build protocols for billing the co-management payment — a $30 per service code (plus a $10 onboarding modifier for initial setup support) that keeps PCPs financially engaged without requiring them to become ACCESS participants.

For Medicare Advantage plan strategists, the model's G-code billing structure and CMS-published reference payer implementation resources create a template for plans to develop their own ACCESS-aligned payment arrangements with contracted digital health vendors — potentially accelerating Star Ratings-relevant chronic disease management at scale.

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2. Model Architecture and Payment Structure

Participation Structure and Eligibility

Participant Definition: ACCESS participation is defined at the organizational level, identified by a single Medicare Part B-enrolled Taxpayer Identification Number (TIN) eligible to bill under the Medicare Physician Fee Schedule. DMEPOS suppliers and laboratory suppliers are explicitly excluded. Organizations not enrolled in Medicare Part B must complete enrollment before applications are fully approved — the RFA warns that the Medicare enrollment process should begin as early as possible given processing timelines.

Required Designations: Each participant must designate a Medicare-enrolled physician as Medical Director — specifically a Doctor of Medicine or Osteopathy, either an employee or under contract — responsible for clinical policies, outcome monitoring, OAP Measure data validation, and compliance with all federal and state requirements. All physicians and non-physician practitioners furnishing or supervising care must be individually Medicare-enrolled, participating providers or suppliers who have reassigned their Medicare billing rights to the participating TIN.

Ongoing Compliance Requirements: Participants must submit monthly claims using model-specific G-codes, transmit electronic clinical updates to beneficiaries' care teams, submit OAP Measures via CMS's FHIR-based Reporting API, comply with HIPAA as covered entities, comply with FDA requirements for any medical device technologies used, and disclose material changes in ownership or licensure. By July 6, 2027, participants must establish connectivity to a Health Information Exchange (HIE), a CMS Aligned Network, or a designated QHIN (for TEFCA exchange), enabling bidirectional clinical data exchange. Also by July 6, 2027, participants must make available one or more APIs meeting the ONC (g)(10) standardized API criterion at 45 CFR § 170.315(g)(10).

Withdrawal Policy: Participants must provide 180 days advance written notice to CMS before termination, must continue serving aligned beneficiaries through the effective date, must notify beneficiaries, and must facilitate appropriate referrals for continuity of care.

Clinical Tracks and Qualifying Conditions

Track	Qualifying Conditions	Key OAP Measures
eCKM	Hypertension, OR two or more of: dyslipidemia, obesity/overweight with central obesity marker, prediabetes	BP, LDL-C, weight/BMI, HbA1c (prediabetes only)
CKM	One or more of: diabetes, CKD (stage 3a or 3b only), ASCVD	BP, LDL-C, weight/BMI, HbA1c (diabetes only); eGFR and uACR (diabetes or CKD, submission required)
MSK	Chronic musculoskeletal pain (pain lasting >3 months)	PROMIS PF + PI, site-specific PROMs (ODI, NDI, QuickDASH, KOOS JR, HOOS JR), Pain Intensity NRS, PGIC
BH	One or more of: depression, anxiety	PHQ-9 (depression), GAD-7 (anxiety), PGIC; WHODAS 2.0 optional

Participants are responsible for managing all qualifying conditions a beneficiary has within their enrolled track — not just the conditions for which the beneficiary was initially referred. Beneficiaries may be simultaneously enrolled in multiple tracks (with the same or different participants), except that eCKM and CKM cannot be held simultaneously — a beneficiary already in eCKM may switch directly to CKM without the standard three-month lock-in period.

Performance Measurement: Specific Targets

Blood Pressure (eCKM/CKM): Control = final systolic BP <130 mmHg; Minimum Improvement = 15 mmHg reduction in systolic BP. Example: a patient entering at 152 mmHg must reach ≤137 mmHg.

Weight (eCKM/CKM): Control = final BMI <30 kg/m² AND no more than 5% weight gain from baseline; Minimum Improvement = 5% weight reduction.

HbA1c (eCKM/CKM): Control for prediabetes = final HbA1c <6.5%; Control for diabetes = <7.5%; Minimum Improvement for diabetes = 1 percentage point reduction.

LDL-C (eCKM/CKM): Control for dyslipidemia = <100 mg/dL; Control for ASCVD (CKM only) = <70 mg/dL; Minimum Improvement for dyslipidemia or ASCVD = 30 mg/dL reduction.

MSK (any/multi-site): Minimum Improvement = 2-point reduction in PROMIS Pain Interference AND 2-point increase in PROMIS Physical Function (T-score). Site-specific minimums include 8-point reduction on ODI (lower back), 8-point reduction on NDI (neck), 10-point reduction on QuickDASH (shoulder/arm/hand), 10-point increase on KOOS JR (knee), 10-point increase on HOOS JR (hip).

BH: Control for depression = baseline PHQ-9 <10, final PHQ-9 <10; Minimum Improvement = 5-point PHQ-9 reduction from baseline ≥10. Control for anxiety = baseline GAD-7 <10, final GAD-7 <10; Minimum Improvement = 4-point GAD-7 reduction from baseline ≥10.

Data submission timing: BP and weight have 15-day clinical validity windows; HbA1c and LDL-C have up to 1-year windows for patients with the qualifying condition, 2 years for others; eGFR/uACR have 1-year windows. MSK and BH PROMs have 15-day validity windows. For MSK and BH, end-of-period measures may be submitted up to 180 days early (early success reporting). For eCKM/CKM, end-of-period measures may be submitted up to 90 days early.

Payment Methodology

Annual OAP Rates by Track and Period:

Clinical Track	Initial Period (Annual)	Follow-On Period (Annual)	Rural Add-On (eCKM/CKM Initial Only)
eCKM	$360	$180	+$15 (connected BP cuff distribution)
CKM	$420	$210	+$15 (connected BP cuff distribution)
MSK	$180	N/A (no Follow-On Period)	N/A
BH	$180	$90	N/A

The Initial Period applies when the participant is treating the beneficiary for the first time in that track within the past two years and at least one OAP Measure is not at target. The Follow-On Period applies when the participant previously managed the beneficiary in the same track within the past two years, or when all baseline OAP Measures are already at target at enrollment. For eCKM and CKM, if the beneficiary is referred by another clinician, the participant qualifies for the full Initial Period rate even if baseline measures are at target — the referring clinician's NPI must appear on the claim.

OAP rates are embedded in eCKM and CKM for the expected device cost of a cellular network-connected blood pressure cuff used for condition management and outcome reporting. The $15 rural add-on applies to rural patients in eCKM and CKM during the Initial Period only.

Multi-Track Discount: When a beneficiary is enrolled in multiple tracks with the same ACCESS participant, CMS applies a 5% discount to the monthly OAP amount of the lowest cost track(s). This does not apply to beneficiary cost-sharing. No discount applies when different tracks are managed by different ACCESS participants.

Payment Mechanics and Withholding Structure

Participants submit monthly claims using track-specific G-codes through MACs. Claims process as "zero-paid" by MACs, with the IPC issuing monthly payments based on validated prior-month claims. Each claim submission constitutes an attestation of active care delivery and ongoing compliance.

Monthly payment flow: During months 1–6, participants receive monthly installments totaling 50% of the total annual OAP amount (one-twelfth per month). During months 7–12, payments are withheld pending end-of-period reconciliation. After the 12-month care period, CMS releases the withheld 50% in whole or in part based on performance adjustment outcomes. Claims must be submitted within 90 days of date of service.

Semi-Annual Reconciliation: CMS assesses performance across the participant's full patient panel, including all beneficiaries whose 12-month care period ended during the prior six-month window, on two adjustment mechanisms simultaneously but applies only the larger of the two (not both compounded).

Performance-Based Payment Adjustments

Clinical Outcome Adjustment (COA):

• Outcome Attainment Rate (OAR): Percentage of aligned beneficiaries who completed their 12-month care period and met all required OAP Measure targets and submission requirements.
• Outcome Attainment Threshold (OAT): Set at 50% for the first 18 months (July 2026 through end of 2027). Increases in subsequent participation years up to a defined upper limit.
• If OAR ≥ 50%: participant receives 100% of withheld OAP amount.
• If OAR < 50%: proportional payment = (OAR ÷ OAT) × full OAP. Example: OAR of 40% → 40 ÷ 50 = 80% of full OAP (20% COA reduction).
• COA capped at 50% reduction (i.e., participants always retain at least 50% of gross OAP even at worst performance, unless subject to termination).

Substitute Spend Adjustment (SSA):

• Substitute Spend Rate (SSR): Percentage of aligned beneficiaries who did not receive listed substitute services from other Medicare providers for the same condition during their ACCESS care period.
• Substitute Spend Threshold (SST): Set at 90% for the first 18 months.
• If SSR ≥ 90%: full OAP. If SSR < 90%: proportional payment = (SSR ÷ SST) × full OAP. Example: SSR of 88% → 88 ÷ 90 = ~98% of full OAP (~2% SSA reduction).
• SSA capped at 25% reduction to total OAP.
• Substitute services include specifically enumerated codes: eCKM/CKM substitutes include ambulatory BP monitoring (93784, 93786, 93788, 93790), Remote Physiologic Monitoring setup (99453, 99473), Diabetes Self-Management Training (G0108), and MDPP (G9880, G9881, G9886, G9887), among others. MSK substitutes include PT evaluations (97161-97163) and OT evaluations (97165-97167). BH substitutes include psychiatric diagnostic evaluations (90791, 90792) and Initial Psychiatric Collaborative Care Management (99492).

FFS Exclusion: ACCESS participants and their affiliated entities (defined as ≥5% ownership interest, operational/managerial control, or reassignment relationship under 42 CFR §424.80) may not submit Medicare FFS claims for aligned beneficiaries during active care periods. Only ACCESS G-codes may be billed for aligned beneficiaries. MAC claims processing systems will automatically suppress FFS billing from ACCESS participants for aligned beneficiaries.

Co-Management Payment for PCPs and Referring Clinicians

CMP G-Code	Track	National Base Rate	Description
G0676	eCKM/CKM	$30 (+ geographic adjustment)	Review of ACCESS update + ≥1 care coordination activity
G0677	MSK	$30 (+ geographic adjustment)	Review of ACCESS update + ≥1 care coordination activity
G0678	BH	$30 (+ geographic adjustment)	Review of ACCESS update + ≥1 care coordination activity
Modifier AC	All tracks	+$10 (first CMP per beneficiary per track)	Initial onboarding and setup support

Billing frequency: up to 3 times per 12-month care period per beneficiary per track (changed from the RFA's "once every four months" language to the webinar's "up to three times per period" — consistent in practical effect). Maximum annual co-management payment: approximately $100 per beneficiary per track. No beneficiary cost-sharing applies. Requires minimum 5 minutes of clinician review time plus documentation of at least one care coordination activity. Eligible practitioners include physicians, NPs, PAs, physical therapists, occupational therapists, clinical psychologists, licensed clinical social workers, registered dietitians, marriage and family therapists, mental health counselors, and others. FQHCs and RHCs may begin billing beginning October 1, 2026.

Model Timeline and Cohort Structure

Milestone	Date
Applications opened	January 12, 2026
Initial application deadline (Cohort 1)	April 1, 2026
First cohort begins	July 5, 2026
Participation Agreement deadline (Cohort 1)	June 1, 2026
New tracks (heart failure, COPD, SUD, tobacco) begin	April 1, 2027
HIE connectivity requirement deadline	July 6, 2027
(g)(10) API requirement deadline	July 6, 2027
ACO calculation incorporation of ACCESS OAPs	January 1, 2028
Subsequent cohorts begin	January 1, 2027, then quarterly through July 1, 2033
Applications close	April 1, 2033
New beneficiary alignment ceases	July 1, 2035
Model performance period ends	June 30, 2036

Rolling applications are processed for cohorts beginning quarterly through July 2033, ensuring at least two years of participation for any approved applicant. Applications received after April 1, 2026 and before October 1, 2026 are considered for a January 1, 2027 start. The model includes a randomized evaluation component — some eligible beneficiaries will be assigned to a control group and rendered ineligible for ACCESS enrollment for 12 months, a standard CMMI evaluation design. Control group assignment is communicated to participants via the Eligibility API's not-eligible-control-group result code.